Let’s Stop Talking About 'Lifestyle Specialties'

One of my favorite parts of residency so far has been talking to M3s about their experience on rotations, and our conversations usually turn, eventually, to their choice of specialty. In one of those recent conversations, a student shared she was interested in Psychiatry, and we talked about all the things she liked about it. After talking about the impactful clerkship rotation she had done, she casually added, "and, you know, the lifestyle." I asked her what she meant by that, and she talked about how the residents seemed less overworked, and how she liked having more time blocked for appointments and thus not being so rushed. I agreed with her, and we got to talking further about the various specialties in medicine, pros and cons of specialty choice, and the nuanced concept of lifestyle as it relates to medicine.

In recent years, the word "lifestyle" has become as popular as any in medicine and medical education. It's not a word you might hear in the physician's office with a patient – or rather, you might hear it, but used differently. Physicians counsel patients all the time about lifestyle changes, meaning: eat less fast food, start exercising, develop a bedtime routine for better sleep. Outside the clinic walls, though, when physicians and medical students talk to each other, they mean something very different by the term. It's usually used in the context of choosing a specialty, particular job, practice type, or work environment on the basis of "lifestyle." Here, it means something else: shorter hours, less call, little overnight work, few weekends, light patient loads, high salary, good reimbursement or pay, and other soft benefits of the job.

This isn't a new consideration. Medical students have long known about the ROADs specialties, which are sold to them early on as a prize that might await them if they study hard and do very well on their boards. These classic "lifestyle specialties" – Radiology, Ophthalmology, Anesthesiology, Dermatology – are traditionally labeled as such because they offer lighter hours on average (or at least more regular hours), high income, and a great "work-life balance." This is another term that's become popular recently, and is really what's behind the idea of a “lifestyle” specialty. Many have blamed this concept on millennials, but the truth is likely more complex. Hard work in one's workplace, and in one's career, must be counterbalanced by time to rest, relax, and recover, or else that worker will ultimately burn out. At a minimum, it's imperative to balance work with rest; at the other end of the spectrum are the physicians who practice medicine as only part of their work, balancing it with time researching, writing, teaching, investing, administrative jobs, or even just hobbies, travel, and more vacation time. It isn't just physicians who care about this, of course, but historically, physicians were driven to work, work, work, and to talk about lifestyle would have been beneath the profession.

Some of this change is no doubt for the better. The rigid and sometimes toxic pride of medicine must change in the face of shifting structures within medicine, division of labor, physician shortages, and interdisciplinary work. Further, I am deeply sympathetic to the desire for balance: I have many interests that don't fall directly within medicine, and I have a family, so I'm not clamoring to work 80 to 100 hours a week. And, as I noted, I am a firm believer in the need for rest and rhythm, in order to maintain health and wellness and to recuperate strength for working in what can often be a draining profession. I’m not defending the argument that more work is actually better, nor am I suggesting that we should avoid talking about these parts of the job; they are important to understand when choosing a career path.

Yet I also struggle to speak of entire specialties, jobs, and careers in such a narrow fashion, as if lifestyle is the main or only consideration. I once heard a general surgeon admonishing her medical students: "If you have to operate, I mean have to, or you'll die, then choose surgery, but if you can fake an interest in something with a better lifestyle, then you should do that." This extreme advice contributes to the messaging that lifestyle trumps the work one does and that career decisions should be based on that one factor. That “something with a better lifestyle” might be ROADs, or it might be Psychiatry, a field growing in popularity – in part, I think, to the perceived lifestyle. This is especially evident to students who rotate through Psychiatry and get more time off than their other clinical rotations. The shift work of Emergency Medicine is also seen this way, as medical students are drawn to the field because of the "lifestyle" considerations - no call, and fewer hours at work.

I like Psychiatry for many nuanced reasons beyond the lifestyle typically associated with it, though I recognize that it's difficult for anyone outside Psychiatry to imagine why I chose it. Having not been interested in Psychiatry, they may recall the parts of it they remember from medical school, coupled with the ancillary details they know now: average salary and average hours at work. When we use this lens, though, we are limited to what we have been exposed to. To hear someone define my career choice only in terms of its pay, or how little I work, or how I work less hard than other specialties, diminishes my profession and my choice of career. Some Psychiatrists work light hours, but many work long hours. Some family doctors work part time, while others work more than 80 hours per week. Emergency Medicine physicians technically work less hours and avoid call, but swinging shift can be disruptive to schedules and plans. Anesthesiologists’ hours are controlled in many ways by the surgeons’ and OR schedules. There are many other examples – evidently, lifestyle varies among the specialties and among practitioners in those specialties. There are myriad reasons to choose any one job or practice type, but none of us chose medicine for the lifestyle only. We can think about it as a factor, but the years of study and training can't be reduced to pay and hours.

I’m not proposing that we stop speaking about lifestyle, but rather that we change the conversation about it at the level of medical education. We should be speaking to students openly about salary, benefits, hours, and call as a component of a specialty, in order to know what they are getting into, but not sell them as the defining components. We should encourage students who show an interest in a field for good, robust reasons – academic interest, areas of emerging research, particular patient populations, personal ties – and resist commenting on the superficial pieces that may be easier to discuss, but risk putting their career choice into an unfortunately small box. When we do this, we limit the scope of our own profession and are in danger of stunting creativity, imagination, and hopeful optimism that we so desperately need from our students, and from ourselves.

Image by Grinbox / Shutterstock

Brent Schnipke, MD is a writer based in Dayton, OH. He received his MD from Wright State University in 2018 and is a first-year Psychiatry resident at Wright State. His professional interests include writing, medical humanities, and medical education. He is also a 2018–2019 Doximity Author.

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